Dental Tribune Middle East & Africa Edition No.2, 2016

Dental Tribune Middle East & Africa Edition | 2/2016 34 ortho tribune 4D Orthodontics From Morphologic Diagnosis to Time Factor By Dr. Matteo Beretta, Italy and Dr. NunzioCirulli,Italy Where do we stand now in modernorthodontics? New methods of orthodontics take great advantage of digital tech- nologies. They do this by preparing an individual treatment plan for the patient, which addresses his/ her complex needs. Such a plan fac- tors matters of biocompatibility and sustainability, which might not be exclusively related to his/her ortho- donticproblems. Our research in this area has re- cently been exploring new scientific grounds that focus on the question ofhownewtechnologiescouldeffec- tively change the way we diagnose health problems and plan the corre- spondingtreatment. A new player is emerging in the tri- dimensionalera,the4Dtechnology! What does it mean? Can we talkofanewrevolutioninap- pliedscience? In 2007, Tiziano Baccetti and Lorenzo Franchi, in their systematic review, entitled “Efficacia e timing della terapia della malocclusione di II Classe con apparecchi ortopedico- funzionali”, concluded that the in- clusion of the pubertal growth spurt in the determination of the treat- ment timing could be considered a key factor in reaching maximal ef- ficiency of the functional therapy of the mandibular growth (Ref.: Ortog- natodonzia Italiana vol. 14, 1-2007:13- 20). This means that the correct tim- ingofthetreatmentcouldbeamajor prerequisite to accomplish its main objectives. The “timing require- ment” is by far a very clear concept but it can be further enhanced by adding an extra degree of dynamic- ity.Let’sseehow! To do this we have to go back in time …. looking for studies on the samesubjectmatter. In 1956, Harold D. Kesling, in an article published in the American Journal of Orthodontics, entitled “The Diagnostic Setup with Consid- eration of the Third Dimension”, said: Good orthodontic casts not only provide exact duplicates of every tooth in the mouth, but they also give a fairly accurate pattern of the apical base. Since neither the apical basenorthetoothsizecanbealtered materially, some intelligent rear- rangements of the plaster teeth, as it appears on the model, can remove confusion arising from pure specu- lation by replacing it with concrete objectivemanipulation. In short, he have just invented the morphologic diagnosis and the diagnosticsetup. Harold D. Kesling further no- ticed: Without dissecting the teeth from the orthodontic models and rearranging them in the most desir- able positions on the available api- cal bases, the orthodontist can only speculate on available options and limitations of the treatment. (Ref.: Am. J. Orthodontics, October 1956, vol.42N°10,pages740-748) Dynamics is the branch of me- chanics interested in studying bod- ies’ motion and its causes or, more clearly,thecircumstancesthatdeter- mineormodifyit. Orthodontics is gradually evolv- ingtowardsamoredynamicconcept of occlusion, of functional harmony and biologic/mechanic interconnec- tion. Luckily, the progress from the old “static concept” of Class I occlu- sion to the present concept of func- tionally supported occlusions is not completelynewtotheorthodontists. This is what W.J. Thompson wrote in 1979 in his article in An- gle Orthodontist entitled “Occlusal Plane and Overbite”. (Ref.: Angle Or- thodontist,1979January49(1):47-55.). Hence, we are not talking of a newconcept! What can these two studies offer toorthodontists? Form and Function, this is what our teachers have taught us to make a correct diagnosis, to set a proper plan of health care and to define the objectives of stability and, above all, the maintainability of the results of ourorthodontictreatments Let’s see a clinical example of how form and function determine diagnosisandprognosis! A patient aged 25 was orthodon- tically treated in the past with fixed orthodontic appliances. He came to our attention due to progressive re- cession of 4.1, increase in sensitivity, and difficulty to maintain proper oral hygiene. The patient has unnec- essarily been brought to us for peri- odontal surgery. Upon examination, we discovered severe gingival reces- sionof4.1associatedwithbuccalroot inclination and traumatic contact with the antagonist for extrusion. It also featured a fixed lower retainer, from 3.2 to 4.2, repeatedly repaired. (Figures1-3) Theoldfixedretentionprevious- ly managed incorrectly has become an active retainer on 4.1 with buccal root torque unchecked. A proper morphologic diagnosis must consid- er the three-dimensional position of the root in the alveolar bone and not just detect the buccal gingival reces- sion, whose single consideration has alreadyledtoatreatmentfailure. The treatment plan involved: (a) removing the old retainer and fixing a lingual appliance by self-ligating brackets i- TTЯ from 3.4 to 4.4 with the purpose of aligning the lower frontal teeth; (b) correcting the root torque of 4.1; and (c) eliminating the occlusal trauma to allow recovery of an adequate periodontal health conditions and secure maintain- ability. The required correction has been completed in 8 weeks from the removal of the old retainer and the simultaneous bonding of the lingual orthodontic appliance. The buccal gingival recession of 4.1 has improved significantly, only thanks to its repositioning in an appropri- ate periodontal environment, which has also improved the conditions for maintainability. The lingual ap- pliance, very well tolerated by the patient, is maintained as a fixed re- tainer.(Figures4-8) In this case, an orthopantomog- raphy had been done before the treatment, which made no apperent morphological contribution to the clinicaldiagnosis. Should a tele-radiography have beusefulinthiscase? Obviously not! How could we then make any use of tele-radiogra- phy? In an editorial in the American Journal of Orthodontics of 2008, Da- vidLTurpinsays: Iftheintraoralpalpationofmax- illary canines in an 8 year-old child is difficult and there is a reasonable suspicion for a complicated erup- tion, you should consider doing a tele-radiography! In the same editorial, we found the following recommendations by theBritishOrthodonticsSociety: - a radiography should be done onlyafteranaccurateclinicalexami- nationandwhenitoffersaneffective diagnosticadvantageforthepatient; - generally, the advantages of a radiographicsurveyexceedtherisks; - the risk level is justified only whenthepatienthasahealthadvan- tagewiththeALARAdose(ALARA:as low as reasonably achievable) (Ref.: Am. J. Orthodontist Dentofacial Or- thop.2008;134:597-8) A review of relevant literature in the University of Oporto, Portugal, published in Progress in Orthodon- tics in 2013, entitled “Validity of 2D- lateral Cephalometry in Orthodon- tics:aSystematicReview,reveals: The literature suggests that the lateral cephalometry has been ap- plied without adequate scientific evidence, irrespective of whether it is mandatory for the diagnosis and without regard to its therapeutic ef- ficacy. (Ref.: Ana R Durão1, Pisha Pit- tayapat, Maria Ivete B Rockenbach, Raphael Olszewski, Suk Ng, Afonso P Ferreira and Reinhilde Jacobs. Pro- gressinOrthodontics201314:31;3-11) This article,as many otherpubli- cations, recommend that additional researchisrequiredonalargernum- ber of patients to clarify better the matter.Themessageisprettyclear. Thecephalometryhasbeenused in orthodontics for long time for di- agnosticpurposesandfortrainingof generations of orthodontists, which helps them understand better the significance of angles and planes. It does nothing more than express numerically what patients’ maxil- lary and cranial bones morphology provides. Ofcourse,withstudyandexperi- ence as fundamental preconditions, wise orthodontists would likely not needthosenumbersatall. Moreover, could we do the ceph- alometry without radiation for a pa- Fig.1.Frontalview Fig.3.Occlusalview Fig.4.Lingualappliance Fig.6.Occlusalviewat theandof treatment Fig.5.Frontalviewat theendof treatment Fig.2.Detailof4.1 ÿPage35 Dr. Matteo Beretta & Dr. Nunzio Circulli, Italy are speakers at 11th CAD/CAM & Digital Dentistry Int'l Conference! 06-07 May 2016 | Jumeirah Beach Hotel, Dubai, UAE